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Overview of US Health Care System
1. An Overview of the U.S.
Health Care System
Chart Book
Centers for Medicare and Medicaid Services
And
Office of the Assistant Secretary for Planning and Evaluation
January 31, 2007
1
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
2. Table of Contents - Section 1
Section 1: Overview of the U.S. Health Care System 8
Table 1.1 National Health Expenditures and their share of GDP, 1980-2015 9
Table 1.2 National Health Expenditures per Capita, 1980-2015 10
Table 1.3 Personal Health Expenditures by Source of Funds, 1960-2004 11
Table 1.4 Health Insurance Coverage for the Under 65 Population, 1980-2004 12
Table 1.5 Personal Health Care Expenditures by Service, 1960-2003 13
Table 1.6 Annual Percent Change in Personal Health Care Expenditures for Medicare, Medicaid, and Total, 1971-2015 14
Table 1.7 Average Annual Growth in Medicare & Private Health Insurance Benefits Per Enrollee, Selected Periods 15
Table 1.8 Concentration of Health Spending, 1987-2002 16
Table 1.9 Factors Accounting for Growth in Prescription Drug Spending per Capita, 1980-2011 17
Table 1.10 Prescription Drug Expenditures by Source of Funds, 1965-2004 18
Table 1.11 Sources of Payment for Nursing Home and Home Health Care, 2004 19
Table 1.12 Number of People Employed in Health Care, 1990-2005 20
Table 1.13 Health Care Employment by Occupation, 1983-2005 21
Table 1.14 Health Care Employment Growth Projections, 2000-2010 22
Table 1.15 Average Annual Salaries of Selected Groups of Workers, 2005 23
Table 1.16 HMO Enrollment by Ownership Status, 1981-2004 24
Table 1.17 Concentration of Managed Care Enrollment, 1988-2003 25
Table 1.18 Managed Care Enrollment by Type of Plan, 1984-2004 26
Table 1.19 Health Care as a Percent of Income by Age, 2004 27
Table 1.20 Annual Growth Rates in the Overall CPI and MCPI, 1993-2005 28
2
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
3. Table of Contents - Section 2
Section 2: International Comparisons 29
Table 2.1 Percent of GDP Spent on Health Care by OECD Country, 1960-2004 30
Table 2.2 Per Capita Spending on Medical Services by OECD Country, 1980-2004 31
Table 2.3 Average Annual Growth in Per Capita Spending by Decade by OECD Country, 1960-2003 32
Table 2.4 Per Capita Health Spending by Type of Service by OECD Country, 2003 33
Table 2.5 Share of Total Health Spending on Outpatient care by OECD Country, 1970-2003 34
Table 2.6 National Health Spending by Source of Funds by OECD Country, 2003 35
Table 2.7 Per Capita Spending on Drugs and other Non-durables by OECD Country, 1970-2003 36
Table 2.8 Drug Spending as a Percentage of Total Health Spending, 1980-2003 37
Table 2.9 Infant Mortality Rates per 1,000 Live Births by OECD Country, 1970-2004 38
Table 2.10 Male and Female Life Expectancy at Birth by OECD Country, 1960-2004 39
Table 2.11 Male and Female Life Expectancy at Age 65 by OECD Country, 1960-2004 40
Table 2.12 Number of Inpatient Discharges and Total Beds per 1,000 persons, by OECD Country, 2004 41
Table 2.13 Average Length of Hosptial Stay for Selected OECD Countries, 2004 42
Table 2.14 Medical Technology and Use of High Technology Medical Procedures by OECD Country, 2004 43
Table 2.15 Selected Indicators of Mobidity by OECD Country, Selected Years 44
Table 2.16 Selected Indicators of Mortality by OECD Country, 2004 45
3
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
4. Table of Contents - Section 3
Section 3: Providers 46
Table 3.1 Number of Hospitals by Type, 1980-2004 47
Table 3.2 Number of Hospital Beds and Occupancy Rates by Hospital Type, 1980-2004 48
Table 3.3 Number of Hospital Beds per 1,000 Persons by State, 2004 49
Table 3.4 Number of Nursing Home Beds & Residents, 1985-2003 50
Table 3.5 Number of Physicians per 100,000 Persons by State, 2004 51
Table 3.6 Distribution of Active Physicians:1950-1998 52
Table 3.7 Percentage of Physicians in Differing Practice Arrangements, 1987-2001 53
Table 3.8 Physician Revenue by Payer, 1986-2004 54
Table 3.9 Physician Participation in Managed Care, 1988-2001 55
Table 3.10 Physician Managed Care Payment Arrangements, 2001 56
Table 3.11 Hospital Participation in HMOs and PPOs, 1987-2004 57
Table 3.12 Hospital Managed Care Payment Arrangements, 2001 58
Table 3.13 Hospital Profit Margins for All Payers and Medicare, 1997-2004 59
Table 3.14 Hospital Payment to Cost Ratios for Medicare, Medicaid, and Private Payers, 1985-2002 60
Table 3.15 Change in Nursing Home Institutionalization Rate for Elderly, 1985-1999 61
Table 3.16 Nursing Home Resident Rate by State, 2003 62
Table 3.17 Number of Hospital Discharges and Average Length of Stay, 1980-2004 63
Table 3.18 Number of Physician Visits per 1,000 Persons, 1990-2000 64
4
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
5. Table of Contents – Section 4, Tables 4.1 to 4.20
Section 4: Public Programs 65
Table 4.1 Public Payers’ Share of National Health Spending, 1980-2010 66
Table 4.2 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 2004 67
Table 4.3 Personal Health Care Expenditures by Type of Service and Percent Medicare Paid, 1980 68
Table 4.4 Where the Medicare Dollar Went, 1980 and 2005 69
Table 4.5 Medicare Trustees Report: Part A Income and Expenses, 1970-2015 70
Table 4.6 Number of Medicare Beneficiaries, 1970-2040 71
Table 4.7 Medicare Beneficiaries as a Share of the US Population, 1970-2030 72
Table 4.8 Medicare Spending for Fee-For-Service Beneficiaries by Income, 2003 73
Table 4.9 Living Arrangements of Medicare Beneficiaries, 2003 74
Table 4.10 Age and Gender of the Medicare Population, 2003 75
Table 4.11 Total Health Care Spending for Medicare Beneficiaries, 2003 76
Table 4.12 Sources of Payment for Medicare Beneficiaries’ Medical Services, 2003 77
Table 4.13 Sources of Payment for Medicare Beneficiaries by Type of Service, 2003 78
Table 4.14 Types of Supplemental Health Insurance held by Fee-for-Service Medicare Beneficiaries, 2003 79
Table 4.15 Medicare Beneficiary Out-Of-Pocket Spending, 2003 80
Table 4.16 Per Capita Out-Of-Pocket Expenses for Medicare Beneficiaries by Type of Insurance Coverage, 1993 and 2003 81
Table 4.17 Distribution of Medicare Enrollees by Functional Status, 2003 82
Table 4.18 Beneficiaries with Poor Health or Functional Limitations by Insurance Status, 2003 83
Table 4.19 Medicare Managed Care Enrollment, 1990-2005 84
Table 4.20 Medicare Beneficiaries with Prescription Drug Coverage,1992-2003 85
5
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
6. Table of Contents – Section 4, Tables 4.21 to 4.40
Section 4: Public Programs 65
Table 4.21 Total Spending for Prescription Drugs for all Medicare Beneficiaries, 1996-2003 86
Table 4.22 Medicare Beneficiaries with Drug Coverage by Primary Source of Supplemental Coverage, 1995 and 2003 87
Table 4.23 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 2004 88
Table 4.24 Personal Health Expenditures by Type of Service and Percent Medicaid Paid, 1980 89
Table 4.25 Medicaid Enrollment by Eligibility Group, 2003 90
Table 4.26 Average Medicaid Payments Per Person Served by Eligibility Group, 1985-2003 91
Table 4.27 Medicaid Enrollees by Eligibility Group, 1975-2003 92
Table 4.28 Total Medicaid Expenditures by Type of Service, FY 2005 93
Table 4.29 Total State Spending and Federal Funds Provided to States, 2004 94
Table 4.30 Medicaid Spending for Long-Term Care, 1999-2003 95
Table 4.31 Births Financed by Medicaid as Percent of Total Births by State, 2005 96
Table 4.32 Medicaid Enrollment by Age, Sex, and Ethnicity, 2003 97
Table 4.33 Medicaid Managed Care Enrollment, 1996-2004 98
Table 4.34 Health Insurance Coverage of Children, 1988-2005 99
Table 4.35 State Children’s Health Insurance Program Spending and Enrollment, 1998-2004 100
Table 4.36 State Children’s Health Insurance Program Plan By State, 2006 101
Table 4.37 State Health Spending as a Percent of Gross State Product, 2004 102
Table 4.38 Share of State Health Spending Financed by Medicare and Medicaid, 2004 103
Table 4.39 Share of State Health Spending Financed by Medicare, 2004 104
Table 4.40 Share of State Health Spending Financed by Medicaid, 2004 105
6
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
7. Table of Contents – Sections 5 and 6
Section 5: Private Health Insurance 106
Table 5.1 Health Spending From Out-of-Pocket and Private Health Insurance, 1980-2010 107
Table 5.2 Changes in Employer Health Insurance Premiums, Overall Inflation, and Workers' Earnings, 1989-2005 108
Table 5.3 Change in Health Insurance Premiums by Firm Size, 1988-2005 109
Table 5.4 Employee Contributions to Health Insurance Premiums, 1988-2005 110
Table 5.5 Average Annual Premium Costs by Plan Type, 2005 111
Table 5.6 Changes in Employee Benefit Packages, 1980-2004 112
Table 5.7 Firms Offering Health Insurance Coverage by Firm Size, 1996-2005 113
Table 5.8 Number of Health Plans Offered by Firm Size, 2005 114
Table 5.9 Private Health Insurance Enrollment by Plan Type, 1988-2005 115
Table 5.10 Employees With a Choice of Health Plans, 1988-2005 116
Table 5.11 Covered Employees in Firms that Offer Health Benefits, 2005 117
Section 6: Uninsured 118
Table 6.1 Out of Pocket Spending by the Under 65 Population by Insurance Status by Income, 2001 and 2003 119
Table 6.2 Out of Pocket Spending by the Under 65 Population by Insurance Status by Type of Service, 2001 and 2003 120
Table 6.3 Percent Uninsured within Age Categories, 1987-2005 121
Table 6.4 Percent Uninsured within Income Categories, 1987-2005 122
Table 6.5 Percent Uninsured by Ethnicity, 1987-2005 123
Table 6.6 The Uninsured by Age, 1987-2005 124
Table 6.7 The Uninsured by Income, 1987-2005 125
Table 6.8 The Uninsured by Ethnicity, 1987-2005 126
Table 6.9 The Uninsured by State, 2005 127
Table 6.10 Impact on Non-Elderly Adults of Being Uninsured, 2006 128
7
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
8. Section 1
Overview of the U.S. Health Care System
8
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
9. Table 1.1
National Health Expenditures and Their
Share of Gross Domestic Product (GDP), 1980-2015
National health spending is projected to continue to increase as a
share of GDP over the next decade.
NHE Projected NHE GDP Share Projected GDP Share
$4,500 25%
Projected
Actual
$4,000
20%
$3,500
$3,000
15%
GDP Share
Billions
$2,500
$2,000
10%
$1,500
$1,000 5%
$500
$0 0%
1980 1990 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Calendar Year
Source: CMS, Office of the Actuary, National Health Statistics Group.
9
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
10. Table 1.2
National Health Expenditures Per Capita, 1980-2015
National health spending per capita is projected to increase rapidly over the next decade.
$13,000
$12,000 $ 12, 357
Actual Projected
$11,000
$10,000 $ 10, 339
$9,000
$8,000 $ 8, 636
$7,000
$ 7, 129
$6,000
$ 6, 280
$5,000 $ 5, 879
$ 5, 485
$4,000
$ 4, 471
$3,000
$2,000
$1,000
$ 1, 067
$0
1980 1998 2000 2002 2004 2006 2009 2012 2015
Calendar Year
Source: CMS, Office of the Actuary, National Health Statistics Group.
10
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
11. Table 1.3
Personal Health Care Expenditures by Source of Funds:
Selected Years 1960-2004
Over the last several decades, both the public and private sector share of health spending
has increased, while the share from out-of-pocket spending has declined.
Dollars in Billions
$23.3 $63.1 $214.5 $609.3 $1,553 $1,877.6
100
14% 13%
23%
27% 5% 7%
55% 40%
80
5%
4% 35%
3% 35%
60
Percent
33%
28%
2% 22%
40 12% 13%
21% 12% 10%
16% 17% 17%
20 17% 18%
12%
21% 16% 16%
8% 12% 11%
0
1960 1970 1980 1990 2002 2004
Calendar Year
Other Public Out-of-Pocket
Total Total
Medicare Other Private
Public Private
Total Medicaid, SCHIP expansion and SCHIP Private Health Insurance
Source: CMS, Office of the Actuary, National Health Statistics Group.
11
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
12. Table 1.4
Health Insurance Coverage for the Under 65 Population, 1980-2004
Over the last two decades, private coverage has declined, public coverage (mostly Medicaid)
has increased a small amount, and the uninsured have grown.
90
83%
80
Any Private
74%
70 69%
ESI
63%
60
50
40
30
18%
Uninsured
20
Any Government
15
18%
10%
10 13
8% Medicaid
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Notes: ESI - Employer Sponsored Insurance. Any Private includes ESI and individually purchased insurance. Any government includes
Medicare for the disabled population.
Source: Tabulations of the March Current Population Survey files by Actuarial Research Corporation, incorporating their historical
adjustments.
12
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
13. Table 1.5
Personal Health Care Expenditures by Type of Service, 1960-2003
The share of health spending on prescription drugs has grown since 1980. Physician share
has stayed about the same while the hospital share grew and then declined.
47.3%
50
41.7%
39.3%
40 35.8%
36.5%
30 25.9%
25.7%
Percent
25.3%
22.9%
22.5%
21.9%
Service
20
16.4%
15.8%
15.6%
15.2%
12.4%
11.4%
10.8%
10
8.2%
8.6%
8.2%
7.7%
6.6%
5.6%
3.6%
2.9%
2.8%
2.1%
1.1%
0.2%
0
Hospital Physician Home Health Prescription Nursing Home Other
Drugs
Percent
1960 1980 1990 2000 2003
Source: CMS, Office of the Actuary, National Health Statistics Group.
13
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
14. Table 1.6
Annual Percent Change in Personal Health Care Expenditures for
Medicare, Medicaid and Total: 1971-2015
While the actual percent changes vary, overall spending for Medicare and
Medicaid tend to rise and fall together.
PHCE Medicare Medicaid
Projected PHCE Projected Medicare Projected Medicaid
40
Actual
Projected
Medicaid Taxes
35 & Donations
Medicare Extended to (1991)
Medicare
Disabled & ESRD Catastrophic
30
(1973) Coverage
Medicaid Act of 1988
Percent
25
Balanced
Budget
20
Refinement
Act (1999)
Medicaid
15 Medicare
Medicare (projected) (projected)
PHCE
10
5
PHCE
Medicare Prospective Balanced Budget Act
(projected)
Payment System (1983) (1997)
0
1971 1975 1979 1983 1987 1991 1995 1999 2003 2007 2011 2015
Calendar Year
Source: CMS, Office of the Actuary, National Health Statistics Group.
14
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
15. Table 1.7
Average Annual Growth in Medicare and
Private Health Insurance Benefits Per Enrollee : Selected Periods
Except for 1993-1997, Medicare has grown slightly more slowly than private health
insurance.
Medicare Private Health Insurance
16
Entire Period Selected Calendar Year Periods
14 12.8
12 10.9 10.9
9.5
10 9.2
7.6
Percent
8
6.4
5.9
6
4.3
4
2
0
4 93 97 -0.2 999 04
00 19 19 20
-2 1
0- 3- 7- 9-
70
-2
97 99 99 99
19 1 1 1 1
Calendar Years
Source: CMS, Office of the Actuary, National Health Statistics Group.
15
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
16. Table 1.8
Concentration of Health Spending, 1987-2002
Health spending remains highly concentrated on a small percentage of people. The top
1% of people account about a quarter of all health spending,
97% 97%97%
Percentage of Expenditures
70% 69%
1987
64%
1996
56% 56%
49% 2002
28% 28%
22%
Top 1% Top 5% Top 10% Top 50%
Population Ranked By Expenditures
Source: Yu, William W. & Trena M.Ezzati-Rice, Medical Expenditure Panel Survey Statistical Brief #81, AHRQ, May 2005.
16
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
17. Table 1.9
Factors Accounting for Growth in Prescription Drug Spending
per Capita, 1980-2011
Drug Prices and Utilization significantly affect prescription drug spending per capita.
Drug Utilization (Number of Prescriptions per Capita)
Drug Prices (Consumer Price Index - Drugs)
14
12.3%
Average Annual Percent Change
12
10.7%
10
2.7 8.3%
8.2% 8.1%
8.0%
7.7%
8.3
8
4.5
6 4.4
4.9 4.5
6.2
8
4
2 4 3.8
3.7
3.5
3.3
*
1.5
0
1988-1993 1993-2003 2003-2004 2004-2005 2005-2006 2006-2010 2010-2015
Calendar Years
Note: Utilization also includes the effects of intensity and population growth. Per capita drug spending in 1990 was $252
* Without the effect of Part D, overall growth would be 8.1% (price: 3.8%, Utilization 4.3%)
Source: CMS, Office of the Actuary, Health Affairs Web Exclusive, Exhibit 6, pp. W70
17
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
18. Table 1.10
Prescription Drugs Expenditures by Source of Funds,
1965-2004
The share of drug spending covered by public and private sources has grown significantly.
100% 4%
4% 14%
90% 22%
27%
80%
24%
70%
60%
46%
50% 48%
93%
40%
63%
30%
20%
32%
25%
10%
0%
1965 1985 2000 2004
Out-of-Pocket Private Health Insurance Public
Note: Percentages may not sum to 100 due to rounding. Drug spending grew from $3.7 billion in 1965 to $188.5 billion in 2004
Source: CMS, Office of the Actuary, National Health Statistics Group.
18
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
19. Table 1.11
Sources of Payment for Nursing Home and Home Health Care, 2004
Most such care is paid for by Medicare and Medicaid.
Nursing Home Home Care
Out-of-Pocket
Medicare 12.3%
14.8%
Out-of-Pocket
29.6%
Private LTC Ins.
12.9%
Medicare
40.8%
Private
Medicaid
LTC Ins.
47.3%
8.4%
Medicaid
34%
Total nursing home and home health care spending in 2004 is $148 Billion
Source: CMS, Office of the Actuary, National Health Statistics Group.
19
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
20. Table 1.12
Number of People Employed in Health Care, 1990-2005
Number of people employed in health is growing.
14
Health Services
12.1 12.3 Employment as a %
11.8
11.2 11.5
12
10.9 of Non-Farm Private
10.4 10.5 10.7
9.8 10.1 Sector Employment
Employment in Millions
9.5
10 9.3
9 7.5% 1990
8.6
8.2 8.0% 1991
8.2% 1992
8
8.3% 1993
8.3% 1994
8.4% 1995
6
8.4% 1996
8.4% 1997
8.4% 1998
4
8.3% 1999
8.2% 2000
8.5% 2001
2
8.8% 2002
9.1% 2003
9.2% 2004
0
9.2% 2005
p
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
19
19
19
19
19
19
19
19
19
19
20
20
20
20
20
20
Note: Not seasonally adjusted. Health Care Employment includes those who work in ambulatory health care services, hospitals, and
nursing and residential care facilities.
Source: Kaiser Family Foundation, Trends and Indicators in the Changing Health Care Marketplace, 2006 Chartbook.
20
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
22. Table 1.14
Health Care Employment Growth Projections, 2000-2010
Over the next decade, health care employment is expected to grow at a rapid rate.
General Health Care Fastest Growing* Specific
100%
Occupations Health Care Occupations
90%
2000-2010 Employment Growth
80%
70%
62%
57%
60% 53%
47%
50%
40% 33%
26%
30% 25%
19%
20% 15%
10% 3%
0%
T o tal S e rv ic e M a nuf a c t uring H e a lt h C a re H e a lt h C a re P e rs o na l & M e dic a l P hys ic ia n H o m e H e a lt h R .N .s
E m plo ym e nt Secto r Secto r P ra c t it io ne rs S uppo rt H o m e C a re A s s is t a nt s A s s is t a nt s A ide s
G ro wt h & T e c hnic a l O c c upa t io ns A ide s
O c c upa t io ns
*Note: Five of the nation’s top 10 fastest growing occupations are in health care.
Source: Dept. of Labor, Bureau of Labor Statistics. Monthly Labor Review. November 2001.
22
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
23. Table 1.15
Average Annual Salaries for Selected Groups of Workers, 2005
Health professionals earn higher than average incomes.
$150,000
$133,717
$125,000
$99,547
$93,515
$100,000
$75,000
$58,843
$57,282 $55,760
$50,000
$39,629
$25,000
$0
All Professional, Physical RNs Dentists Pharmacists Physicians
Workers Technical, Therapists
Health Professionals
Specialty
Workers
Source: National Compensation Survey: Occupational Wages in the US, June 2005 . US Department of Labor, July 2006.
23
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
24. Table 1.16
HMO Enrollment by Ownership Status, 1981-2004
The proportion of HMO enrollees in not-for-profit plans stabilized in 1997.
% Non-Profit % For-Profit
100%
12.0%
26.0%
80%
46.2%
52.2%
59.7%
62.7% 61.7%
62.6%
63.3% 63.5%
63.7% 64.0%
60%
88.0%
40%
74.0%
53.8%
47.8%
20% 40.3%
37.3% 38.3%
37.4%
36.7% 36.5%
36.3% 36.0%
0%
1981 1985 1989 1993 1997 1998 1999 2000 2001 2002 2003 2004
Total HMO enrollment in 2004 = 66.1 Million
Note: HMO enrollment includes enrollees in both traditional HMOs and point-of-service (POS) plans through: group/commercial plans,
Medicare, Medicaid, the Federal Employees Health Benefits Program, direct pay plans, supplemental Medicare plans, and unidentified
HMO products.
Source: Kaiser Family Foundation. Trends & Indicators in the Changing Health Care Marketplace, 2006 Chartbook.
24
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
25. Table 1.17
Concentration of Managed Care Enrollment, 1988-2003
Half of managed care enrollees are enrolled in the nation’s 10 largest
managed care firms.
80
70 66.5
65.0 65.2
Percent Enrolled in 10 Largest Firms
64.1 66.0
60 56.2
54.6
50 48.0
45.8 48.0
40
30
20
10
0
*
1988 1991 1994 1997 1998 1999 2000 2001 2002 2003
*Note: The decrease in concentration does not represent a decline, but rather a change in the methodology.
Note: The largest national managed care firms include Kaiser Foundation Health Plans, UnitedHealth Group, WellPoint Health
Networks, Aetna, and Health HMO enrollment includes enrollees in both traditional HMOs and point of service plans.
Source: Kaiser Family Foundation. Trends & Indicators in the Changing Health Care Marketplace, 2005 – Chartbook.
25
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
26. Table 1.18
Managed Care Enrollment by Type of Plan, 1984-2004
Mixed model HMO plans grew rapidly before 2000 and declined less rapidly after 2000.
78.9
74.2
80
Staff Group Network IPA Mixed
66.1
63.3
70
32.1
60
Enrollees (in millions)
28.5
23.1 28.9
50
38.8
40 31.4
6.7
33.5 29.9
30
27.5 21.5
13.5 16.2
15.1
20
5.6 3.9
2.9
8.3 8.3
3.3 7.1
3.5
10 8 9.7
6.6 8.7 7 7.4 7.2
4.3 2.4
2.1 0.8 0.4 0.2 0.2
0
1984 1988 1992 1996 2000 2002 2004
Mixed NA NA 17.3% 36.4% 40.0% 38.4% 43.7%
IPA 19.5% 43.0% 41.7% 43.4% 41.9% 40.2% 32.6%
Network 23.3% 18.0% 10.0% 5.3% 8.9% 11.2% 12.5%
Group 43.6% 25.4% 24.8% 13.7% 8.8% 9.9% 11%
Staff 13.6% 13.6% 6.2% 1.2% 0.4% 0.2% 0.3%
Note: Plans analyzed are comprehensive HMO plans. Traditional HMOs and point of service plans are included, managed
care carveouts for selected services such as behavioral health are not included. Enrollment includes group and commercial
plans, Medicare, Medicaid, Federal Employee group health program, and others.
Source: Kaiser Family Foundation, Trends & Indicators in the Changing Health Care Marketplace, 2006 Chartbook.
26
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
27. Table 1.19
Health Care as a Percent of Income by Age, 2004
Those over 65 and those with incomes under $20,000 spend a higher percentage of their
income on health than other groups.
By Age Group By Income Level
P ercen t of In com e S p en t on H ealth
16 15%
16
P ercen t o f In co m e S p en t o n Health
14
14
11.4%
12
12
10
10
6.9%
8
8
5.6% 5.0%
6
6
3.8% 3.2%
2.9%
4 4
2 2
0 0
Under 35 35 to 54 55 to 64 65 and Less than $20,000 to $50,000 to $70,000
over $20,000 $49,999 $69,999 and above
Age Group Income Level
Source: Dept. of Labor, Bureau of Labor Statistics, Consumer Expenditure Survey.
27
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
28. Table 1.20
Annual Growth Rates in the Overall Consumer Price Index (CPI) and
Medical-Specific Consumer Price Index (MCPI), 1993-2005
Medical prices have risen faster than overall consumer prices.
7.0%
6.0%
5.0%
MCPI
4.0%
CPI
3.0%
2.0%
1.0%
0.0%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
CPI MCPI
Source: Dept. of Labor, the Bureau of Labor Statistics.
28
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
29. Section 2
International Comparisons
29
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
30. Table 2.1
Percent of GDP Spent on Health Care by OECD Country, 1960-2004
The U.S. has had a higher share of GDP spent on health than the OECD median for
the past four decades.
16.00
15.3
14.00
11.9
12.00
10.6
9.9
10.00
9 8.8
8.7 8.5
8.1
Percent
8
8.00
7.1 7
7
6.4
6.2
6 5.9
6.00 5.6
5.4 5.1
4.5 4.5
3.9
4.00
3
2.00
0.00
Canada United Kingdom Japan** Germ any* United States
1960 1970 1980 1990 2004
Median: 3.9% 5.1% 6.8% 7.5% 9.6 %
*For 1960, no data was available.
**2003 data was used because 2004 were not available.
Note: The data is arrayed by spending growth from 1990 to 2004. The medians include all OECD countries.
Source: OECD Health Data 2006.
30
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
31. Table 2.2
Per Capita Spending on Medical Services by OECD Country, 1980-2004
US spending is growing rapidly compared with other OECD countries.
5000
$ 4,451
4500
4000
$ 3,408
3500
3000
2500 $ 2,308
$ 2,153
$ 2,027 $ 1
$1,984 $ 2,132
,951
2000 $1,639
$1,423
,445 $ 1,406
$1
1500 $1,348 $1,365
1000 $ 783
$ 675 $ 827
$ 617
500
0
Canada France Germany Japan United States
1980 1990 2000 2004
* 2003 Data Used for Germany and Japan
Source: OECD Health Data, 2006
31
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
32. Table 2.3
Average Annual Growth in Per Capita Spending by Decade
by OECD Country, 1960-2003
Health spending growth over the last decade is lower in OECD countries than in prior decades.
20
18.0
18
16
14.1
14 13.5
13.0
12 11.6
11.1 11.1
10.3
Percent
9.9 9.9
10 9.5
8.8 8.9
8.3 8.0 7.5 7.6
8
6.8
6.3 6.5 6.2
6.0
5.7
6 5.6
5.1
4.2
4.4 4.3 3.9
3.7
4
2
0
Canada France United States Germ any Japan^ United Kingdom ^
1960-1969 1970-1979 1980-1989 1990-1999 2000-2003
^ Average annual change calculated from 2000-2002
Note: Each bar represents the average annual nominal growth over the decade. The data is arrayed by spending growth from 1990 to
1999. The medians include all OECD countries.
Source: OECD Health Data 2005.
32
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
33. Table 2.4
Per Capita Health Spending by Type of Service by OECD Country, 2003
Per capita outpatient spending in the US is almost double inpatient spending. In other OECD
countries per capita inpatient spending is greater than outpatient spending.
$6,000
$380
$5,000
$709
$131
$4,000
$3,000
$2,473 $256
$89 $70
$467
$247
$509 $581
$167
$2,000 $12 $202 $454
$13
$113
$51
$162
$843 $670 $666
$675
$1,000
$1,551
$1,114
$1,053 $1,056
$766
*
$0
United States Japan Germany France Canada
Inpatient Outpatient Ancillary Home Health Drugs Nursing Home
Source: OECD Health Data 2006.
33
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
34. Table 2.5
Share of Total Health Spending on Out-Patient Care by OECD
Country, 1970-2003
In 2003, the U.S. spent the highest percent of total healthcare spending on out-
patient care; In 1970 Japan spent an even higher percent of total health care
spending on outpatient care
60%
50% 48.4%
44.6%
43.3%
43.5%
43.9%
39.6%
40%
33.4%
31.3% 31.9% 32.3%
31.6% 30.4%
31.2%
30% 25.1% 26.1%
25.3%
25.3%
22.6%
20.8% 20.9%
20%
10%
0%
Japan Canada Germany United States
1970 1980 1990 2000 2003
Source: OECD Health Data 2006
34
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
35. Table 2.6
National Health Spending by Source of Funds by OECD Country, 2003
Source of funding varies significantly by country. For instance, out-of-pocket spending ranges
from 8% to 18% of health spending, with the U.S. at about the median.
100%
8% 10%
14% 15%
1% 18% Out-of-Pocket
90%
4%
Payments
12% 1%
4%
0.9%
9%
80%
13%
Percent of Total Health Expenditure
All Other Private
2%
70%
Funds
37%
60%
Private Insurance
50%
68%
75%
40% 13%
69%
Social Security
30%
Schemes
20%
32%
General
10% 17%
Government, Excl.
9%
4% Social Security
0%
France Germany United States Canada Japan
Source: OECD Health Data 2006
35
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
36. Table 2.7
Per Capita Spending on Pharmaceuticals and Other Non-Durables
by OECD Country, 1970-2003
Variation across countries is increasing. Recent growth in North America is most rapid.
1970 1980 1990 2000 2003
$709
$700
$572
$600
$539
$514 $498
*
$500
$438
$425
$398
$367
$400 $363
$300
$258 $252
$248
$239
$202
$200
$128
$123 $112
$96
$100 $67 $49
$43 $43
$34
$0
Japan Germany Canada France United States
Expenditures in U.S. dollars using purchasing power parity rates.
Note: Data is arrayed by spending levels for 2003. Japan not available for 1970.
Source: OECD Health Data 2006.
36
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
37. Table 2.8
Drug Spending as a Percentage of Total Health Spending
by OECD Country, 1980-2003
Although, recent drug spending in the United States on this
measure has grown, it is still low compared to other OECD
countries
21.4
21.2
20.3
18.7
18.8 18.4
17 16.9
15.9 16
14.6
14.3
13.6 12.4
13.4 11.7
9 9.1
8.00 9
Canada France Germany Japan* United
States
1980 1990 2000 2003
*2003 data for Japan is not available; 2002 was used
Source: OECD Health data, 2006.
37
Centers for Medicare & Medicaid Services
Office of the Assistant Secretary for Planning and Evaluation
